Addressing the Global Health Crisis: Universal Health Protection Policies 21
midwives. However, of the 26 million needed health workers in 2014, as much as 10.3 million health workers are globally missing: The urban areas of the world are short of 3
million health workers, and the rural areas are short of 7 million.
Currently, these workers are not trained and not employed to provide urgently needed quality services. This crisis needs to be urgently addressed in order to realize the
right to health for all that is heavily depending on the service delivery through skilled doctors, nurses and midwives.
The health worker crisis is rooted in failure of paying attention to the most valuable asset of health systems: Those who care. Addressing the global shortage requires
an action plan consisting of multiple measures ranging from training and recruiting a sufficient number of health workers and distributing them in an equitable way within
countries to providing them with decent working conditions.
Providing decent working conditions can considerably increase retention rates and thus reduce the very high turn-over rates in some countries and especially among rural
areas. This includes adequate wages that are necessary to ensure quality health care and to prevent health workers from migrating to countries where better conditions are offered.
In this context it is also important to address wage disparities across regions, and between general practitioners and specialists. Public authorities need to be exemplary
employers and procurers. Thus, expenditure of public funds and any contract for health- care provision must include clauses ensuring decent wages.
2
At the same time, non- financial incentives are needed to increase work motivation and reduce turn-over rates, e.g.
through recognition, career development, and further qualification. Key instruments to achieve the necessary conditions include laws and regulations,
collective agreements and other mechanisms for negotiation between employers’ and workers’ representatives, and arbitration awards. The right to organize and bargain for all
health-care workers is crucial. Collective bargaining is the best way to negotiate workplace arrangements that attract the necessary number and quality of health-care workers.
Finally, with regard to migration of health workers, bilateral and multilateral arrangements are needed with a view to compensate for training costs and avoiding brain
drain. Upholding decent work conditions is particularly important in times of economic
and financial crises, when the demand for health care services and the workload are usually increasing.
In general terms, decent working conditions for health workers, universal health protection and sustainable development go hand in hand. It leads to reduced absenteeism
and create spill over effects to the whole economy.
4.4. Providing financial protection for equity in access
Providing financial protection when sick is crucial to ensure that needed health care and loss of income is available. This requires access to health services that are not
impoverishing e.g. in terms of private OOP and income replacement during sickness. In many countries, both criteria are not or insufficiently fulfilled. During recent financial and
2
ILO Labour Clauses Public Contracts Convention, 1949 No. 94.
22 Addressing the Global Health Crisis: Universal Health Protection Policies
economic crises, it could be observed that OOP even increased: In Tanzania the average annual increase in OOP between 2007 and 2011 amounted to as much as 34.6 per cent, in
Equatorial Guineas to 32.2 per cent and in countries such as Cambodia, Paraguay and Turkmenistan to between 12 and 16 per cent table 4. Thus, the extent of financial
protection in times of sickness is reduced.
The shift of burden for health care from the public purse to individuals and households has a particularly severe effect on lower income groups, given the regressive
impact of OOP. As a result, gaps in coverage and access between rich and poor are widening.
Table 4: Average annual increase in OOP, selected countries, 2007
–11 percentages
Country Average annual increase in OOP, 2007-2011
, constant US per capita
Tanzania 34.6
Equatorial Guinea 32.2
Turkmenistan 16.7
Paraguay 15.1
Cambodia 12.1
Russian Federation 9.2
China 7.2
Sri Lanka 5.6
Rwanda 5.3
Source: WHO, National Health Accounts, 2013.
Also financial protection from loss of income is far from universal. Sickness benefits and sick leave are crucial to addressing deteriorating health, health-related poverty
and loss of productivity. Paid sick leave induces economic returns due to improved health and economic productivity as it
• allows workers to recuperate rapidly;
• prevents more serious illness and disability developing;
• reduces the spreading of diseases to co-workers and beyond.
On the other hand, working while sick might result in high economic costs due to a higher number of people in need of treatment for even more severe signs of ill-health.
Economist Intelligence Unit, 2014. Also, the lower productivity of sick workers has been found to slow down growth and development. Thus the absence of sick leave creates
economic costs and avoidable health expenditure Scheil-Adlung and Sandner, 2010.
There are widespread inequalities both within and across countries concerning the provision of financial protection of loss of income during sickness and related sick leave.
Mostly concerned are workers in the informal economy and their families. These gaps need to be closed in order to achieve universal health coverage resulting in equitable
shared wealth and sustainable development.
Addressing the Global Health Crisis: Universal Health Protection Policies 23
Box 1 Financial protection of loss of income during sickness and
paid sick leave
While paid sick leave legislation exists for formal sector workers in 145 of about 190 countries globally, the benefits provided differ widely with regards to definition of work, wages covered, level of income
replacement, duration of payments and other specific conditions. Provisions include both time off work and wage replacement during sickness.
• In countries that offer financial protection for loss of income during sickness, income replacement rates vary between lump sums in 14 per cent of all countries and 100 per cent of wages in 21 per cent of all
countries. More than half of countries provide for replacement rates of between 50 and 75 per cent of wages. • The wage replaced also varies, and may be limited, for example by a ceiling or the exclusion of
supplements. The wage replacement might further be subjected to means testing and waiting times. The period of leave also varies widely: out of a total of 145 countries reviewed, 102 countries provide for one month or
more, while seven provide under seven days. However, even in countries where financial protection for loss of income during sickness exists, workers
in the informal economy are usually totally excluded from income replacement during sickness. Even those who are covered frequently face barriers to accessing paid sick leave, given the fear of losing their jobs, particularly
in times of economic crisis andor high unemployment
Source: Scheil-Adlung and Sandner, 2010.
4.5. Embedding universal health protection in national floors of social protection
